After multiple delays, the North Carolina Department of Health and Human Services said it is “on track” to implement a specialized Medicaid program this summer designed for beneficiaries with complex needs.
These so-called “customized plans” are now scheduled to launch on July 1 and are expected to reach about 150,000 existing Medicaid enrollees who need more extensive care and support than the average enrollee. Many people with intellectual or developmental disabilities, traumatic brain injuries, complex mental illnesses and substance abuse disorders will be transferred to the program, according to DHHS.
Unlike standard Medicaid plans, the customized plans will be administered by a network of four state-funded behavioral health organizations (LME-MCOs). For the past decade, these regional managed care organizations have been providing behavioral health services to people with complex needs across the state, sometimes operating under a cloud of controversy.
Now, they are tasked with connecting tailored program participants with physical and mental health care providers.
These tailor-made programs were originally planned to come online in December 2022, but DHHS delayed the launch to give the LME-MCO more time to prepare. Last year, the department announced more delays, citing a lack of support from some providers.
Jay Ludlam, the state’s deputy secretary of state for Medicaid, gave lawmakers an update on the program as part of Tuesday’s meeting of the Medicaid Joint Legislative Oversight Committee. He said the LME-MCO had “made significant progress in closing the remaining gaps in its network”.
Push for more providers
Ludlam told the committee that DHHS developed internal “disruption standards” after the latest delay. The department’s goal is to ensure that at least 80 percent of customized plan participants’ “current relationships with providers will not be disrupted.”
“Our focus is on those […] “We also see pressure from others who want to ensure that we As a sector we recognize that this is about more than just delivering a service; [but] Who is providing these services…that matters to these families. ”
He said federal regulators were satisfied with last spring’s 80% goal, but they want at least 90% of participants in state-tailored plans to have the option to stay with their current providers for the plan to launch this July.
That angered committee member Sen. Ralph Hayes (R-Spruce Pine), although he has long been critical of the LME-MCO.
Hise said he is concerned that higher standards required by the Centers for Medicare and Medicaid Services will force LME-MCOs “to sign contracts that may not be in the best interest of their systems.” He said some providers were already unhappy with the reimbursement rates for services provided by the LME-MCO.
“Then CMS stepped in and said, ‘First, you have to have 80 [percent] Now you must have 90 [percent]”All of a sudden these contracts were being signed,” Hayes said. “I mean, there’s someone stepping in in the contract dispute to tell them who they have to sign with and, in fact, at what price they have to sign.”
Ludlam responded by pointing out that issues with supplier contracts “sometimes have nothing to do with money.”
“They’re about how many lives are managed by customized plans, and it’s not enough that the system basically doesn’t bother to pick up a pen and sign these contracts,” he said. “By focusing on members’ needs and of course monitoring the potential impact on rates, I do believe that not only can we protect people through this process, but that we will be able to go live on July 1.”
One factor in creating Medicaid was the pursuit of “network adequacy”—the ability of patients to find the care they want and need close to home. That means the plan’s administrators must contract with hundreds or even thousands of health care providers throughout the region.
Ludlam noted that two of the state’s LME-MCOs recently contracted with a “large system” to receive tailored plans. Ludlam declined to name the system, but Charlotte-based Atrium Health has previously been considered a key holdout in the state’s fight for health care providers. A spokesperson for Atrium did not immediately respond to an email from NC Health News on Wednesday.
Ludlam said DHHS has not yet “regained” the potential disruption to existing patient-provider relationships since the unnamed system came online.
“If I were to highlight any potential risk of going online, it would be whether a tailored plan would be able to wind down some of the other contracts that are necessary to minimize disruption to consumers and members,” Ludlam said. .
He added that if the LME-MCO has not contracted with enough providers by then to meet CMS requirements, DHHS will make a “continue or no-continue decision” in April, the July 1 launch date.
“If we do see a high risk of potential harm to individuals from members, we will take the necessary steps to protect people,” Ludlam said of the possibility of another postponement. “We want to work closely with CMS to To make sure that if they declare we can’t come online, they do so based on the best available data and for all the right reasons.”
Launched with LME-MCO
Ludlam said the burden of contracting with enough providers to maintain continuity of care for patients in customized plans will fall primarily on LME-MCOs. He said they knew “individuals who may be at risk” and “where they are.”
“The work will fall on them,” he said. “I think overall they are very close to contracting those care teams and we will continue to monitor that over the next few months.”
The implementation of the customized plan will follow the consolidation that will see the state have four LME-MCOs instead of the previous six. Second. DHHS Superintendent Kody Kinsley ordered the consolidation in November to streamline implementation of the program.
Trillium Health Resources took control of Eastpointe Human Services following the merger, creating a single organization to serve 46 counties in eastern North Carolina. Another LME-MCO, Sandhills Centre, was dissolved during the merger process.
The remaining organizations include Vaya Health, which serves much of the western part of the state, and Alliance Health and Partners Health Management, which cover several counties in central North Carolina.
Ludlam said his “day one goals” for customized plans are to “make sure members have cards in their hands, health plans have adequate networks, providers are getting paid, and members have access to those health plans to understand their interests, knowing who they’re assigned to, and making sure they’re getting care.”